This pre–post study compared patients who received medication reconciliation that was usual care at the time of hospital discharge to patients in the intervention arm who had decision support for deprescribing. Although the intervention did lead to more discontinuation of potentially inappropriate medications, there was no difference in adverse drug events between groups. The authors suggest larger studies to elucidate the potential to address medication safety using deprescribing decision support.

Constructive feedback is a pillar of strong safety culture. Through resident and attending physicians focus groups at a single institution, investigators found that cultural emphasis on politeness and excellence hindered all parties' ability to provide honest feedback. The authors advocate for transitioning to a culture of growth, which would shift their institution toward a more just culture.

Regulatory agencies rely on physician reports of adverse events associated with medical devices in order to identify safety concerns. This qualitative interview study found that most physicians who implant devices do not regularly report adverse events related to particular devices. The authors recommend that postmarketing surveillance of medical devices be redesigned to foster detection of adverse events.

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Calculation errors in weight-based dosing can lead to serious adverse medication events in children. This simulation study randomized residents in a pediatric emergency department to receive either a reference book with precalculated weight-based dosing for medications or a card providing dose per body weight that required manual calculation. Each resident completed two scenarios, one with the precalculated doses and one requiring medication calculations. Although there was no statistically significant difference in overall error rates, errors for continuous infusions and 10-fold errors for bolus medications were significantly lower in the precalculated dose group. This study demonstrates that precalculated medication doses may decrease rates of certain high-priority medication prescribing errors. A past WebM&M commentary discussed an incident involving a pediatric dosing error.

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This validation study found that diagnostic codes in administrative data for hospital-related complications such as pressure ulcers, falls, and adverse drug events accurately reflect the presence of these events in the medical record. This suggests that administrative data can be used to assess the incidence of these complications.

This focus group study examined leadership, clinician, and administrator perspectives on implementation of an adverse event surveillance system. A trained clinical observer assessed triggers designed to indicate a possible adverse event in general medicine inpatient ward settings. Participants supported the approach and involvement of frontline staff in safety surveillance to foster a safety culture and enhance patient safety education for trainees.

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This study estimated a cost of approximately CAD $260,000 over 4 years to develop and run a safety learning system for family physician clinics in Calgary, Alberta. Policy makers and payers may need to determine whether there is an adequate return on investment for the sustainability of these types of programs.

A cornerstone of the medication reconciliation process is assembling the best possible medication history—the gold standard list of a patient's prescription and over-the-counter medications. This cohort study, conducted in an emergency department (ED) in Quebec, compared the medication history obtained by ED staff with the gold standard list of dispensed medications from their community pharmacy. The overall concordance between the two medication lists was poor, and most concerningly, more than 75% of patients had at least one medication noted in their pharmacy list that was not known to the ED. These errors of omission occurred most frequently for medications that were prescribed episodically (i.e., antibiotics) or on an as-needed basis (i.e., pain medications). The development of health information exchanges that give hospital providers direct access to pharmacy records could prevent such errors. A serious medication error due to a problem with medication reconciliation is described an AHRQ WebM&M commentary.

This qualitative study identified key elements of successful local safety interventions. One prominent strategy was stakeholder ownership of a patient safety issue in a supportive interprofessional learning community.

Checklists have been shown to improve patient safety and clinical outcomes when used in combination with other interventions to increase adherence to proven safety strategies. The use of checklists to prevent diagnostic errors has been advocated as well. In this study, medical students, residents, and cardiology fellows were instructed to use a checklist while interpreting electrocardiograms (ECGs). Use of the checklist increased the accuracy of ECG interpretation for all groups and was most effective with the least experienced clinicians. As ECG interpretation errors are common and have serious clinical consequences, checklists such as this have the potential to improve patient care.

Safe patient care requires effective communication between health care providers. Hospitals currently use various communication strategies including alphanumeric pagers, smartphones, and Web-based communication tools. The utility and effectiveness of many such systems have not been tested. This ethnographic study of five teaching hospitals discusses the potential benefits and unintended effects of different communication systems. For instance, smartphones made it easier to respond to requests, but seemed to increase interruptions. An AHRQ WebM&M commentary illustrates a serious adverse event resulting from a smartphone interruption.

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The effect of electronic medical records and computerized provider order entry (CPOE) on medical education is unclear. This qualitative study identified five areas in which CPOE could positively or negatively affect the educational process.

This study found that 82% of providers reported an emotional response after a patient incident, regardless of whether patient harm was significant or avoided. The authors advocate for appropriate vehicles to support second victims.

Journal Article > Study

A recent systematic review found evidence that patient outcomes do worsen in association with the academic year-end turnover of resident physicians. However, this methodologically sophisticated Canadian study found no evidence of worsened patient outcomes in July at a single teaching hospital.